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General NPI Number Information
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NPI Number | 1407384233
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Entity Type | Individual
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Provider Name | KIMBERLY DIANNE PETERSON LISW
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Gender | Female
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Dates
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Enumeration Date | 05/24/2017
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Last Update Date | 12/27/2024
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Provider Practice Location Address
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Address Line | 6601 SW 9TH ST
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City | DES MOINES
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State | IA
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Zip | 50315-6138
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Country | US
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Telephone | 515-643-8350
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Fax | 515-643-5824
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Provider Business Mailing Address
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Address Line | PO BOX 1475
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City | DES MOINES
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State | IA
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Zip | 50305-1475
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Country | US
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Telephone | 515-643-8350
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Fax | 515-643-5824
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 06171
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 06171
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License Number State | IA
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